Uveitis andFloaters

Dr Corina ChilibeckClinical Research Fellow

Dr Monika Pradhan, Dr Tahira MalikDr Mark DonaldsonConsultant Ophthalmologists

Uveitis• Inflammation of uveal tissue

o Iris, ciliary body, choroid• Classification

o Anterior - iriso Intermediate – ciliary bodyo Posterior – choroido Panuveitis

Associations of uveitis• Idiopathic

• HLA B27 +veo Inflammatory bowel diseaseo Ankylosing spondylitiso Psoriatic arthropathyo Reiter’s syndrome

• Juvenille chronic arthritis

• Sarcoidosis

• Behcets

• Collagen vascular disorderso SLEo Polyarteritis nodosao Wegener’s granulomatosis

• Infectiono Toxoplasma, Toxocara, Lymeo HSV, HZV, HIV, CMVo Tuberculosis, syphilis, leprosyo Candidiasis

• Trauma – sympathetic ophthalmia

Anterior Uveitis - Symptoms

• Aching pain

• Redness

• Photophobia

• Blurring of vision

• Pain on accommodation

Anterior uveitis- signs

Lens

• Decreased visual acuity

• Circum-ciliary conjunctival injection

• Small or irregular pupil

• Inflammatory products in AC

• Sequelae

Inflammatory Products• Cells – graded as +1 to +4

• Protein (flare) - +1 to +4

• Fibrin – Grade +4 flare

• Keratic precipitateso Fine, non-granulomatouso Mutton-fat, granulomatous

• Iris nodules – Koeppe, Busacca

Keratic precipitates• Non-granulomatous • Granulomatous

Hypopyon

Sequelae• Posterior synechiae• Seclusio pupillae• Occlusio pupillae• Iris bombè• Sectoral iris atrophy - HZO• Low IOP - hypotony• Glaucoma• Cataract• Cystoid macular oedema• Neovascularisation

Posterior synechiae

Glaucoma

• Inflammation of the trabecular meshwork

• Steroid responsive glaucoma – in 20% due to topical treatment

• Mechanical - ‘pupil block’ glaucoma

Iris bombè – pupil block glaucoma

Herpes zoster ophthalmicus

Posterior uveitis - symptoms

• Floaters

• Blurred vision

Posterior uveitis- signs• Inflammatory products • Visible focus of chorioretinal inflammation• Inflammatory sequelae

o Macular oedemao Vascular sheathing / occlusionso Optic disc swelling

Inflammatory products - Vitritis

Image used with patient permission

Retinal vascular sheathing

Retinal vascular occlusions

Cystoid macular oedema :changes in blood-retinal barrier

Inflammatory focus:commonly Toxoplasmosis

Toxocara

Sarcoidosis:panuveitis,optic neuropathy

Management of UveitisAnterior uveitis Posterior/panuveitis

• Topical steroids (intensive and early)

• Cycloplegics (pain relief and prevent posterior synechiae)

• Topical / oral Antivirals (aciclovir) –HSV, HZO

• Local steroid injections (subconjunctival / sub tenons)

• Systemic steroids

• Orbital floor / posterior subtenonsSteroid injection

• Systemic steroids

• Antibiotics, anti-TB therapy

• Antivirals – oral (HZO, CMV, HIV), intravitreal ganciclovir (CMV)

• Immunosuppresion

Floaters: Causes

• Posterior vitreous detachment - commonest• Blood

oNeovascularisation e.g. diabeteso Torn peripheral retina

• Inflammatory products – intermediate / posterior uveitis

History...

• Onset• Flashing lights• Reduced vision• Other symptoms e.g. field loss• Other history - ocular e.g. myopia, surgery, trauma

- systemic e.g. diabetes

Retinal Tear

Floaters –

haemorrhage / PVD

Photopsia / flashes –

traction at edge of tear

Retinal detachment

• Secondary to PVD and retinal tear

• Floaters / flashes and loss of field

• ‘Curtain’ effect

Diabetic Eye Disease:neovascularisation at optic disc

Diabetes: pre-retinal and vitreous haemorrhage due to neovascularisation

Vitreous haemorrhage:blurred vision and floaters

sub

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